Download ECG Screening in Athletes: How does the Seattle Criteria Help?

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ECG Screening in Athletes: How
does the Seattle Criteria Help?
Ed Kornoelje DO, FAOASM
Medical Director Metro Health Sports
Medicine and the Primary Care
Sports Medicine Fellowship
Clinical Assistant Professor MSU-COM
Medical Director Keeping the Beat
Objectives
•  Define the Seattle Criteria.
•  Identify scope of problem.
•  Understand how we got “here.”
•  Review new ECG screening criteria pearls.
•  Identify a few current programs.
•  **Understand how the Seattle Criteria may help
practitioners interpret ECG’s in students/
athletes and how to learn to apply the Criteria.
Question:
•  What is the goal, reduction of sudden cardiac
death (ultimately) or finding athletes at higher
risk for sudden cardiac death?
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Seattle Criteria
•  Feb 13/14 2012 an international group of experts in
sports cardiology and sports medicine convened in
Seattle, Washington to define contemporary
standards for ECG screening in athletes.
•  Objective of meeting was to develop a
comprehensive training resource to help physicians
distinguish normal ECG alterations in athletes from
abnormal ECG findings that require additional
evaluation for conditions associated with SCD.
!  Drezner JA, Ackerman MJ, Anderson J, Br J Sports Med 2013;47:122-124.
Basis for Meeting
•  Sudden cardiac death is the leading cause of death in
athletes during sport.
•  Whether obtained for screening or diagnostic purposes,
an ECG increases the ability to detect underlying
cardiovascular conditions that may increase the risk of
SCD.
•  In most countries, there is a shortage of physician
expertise in the interpretation of an athlete’s ECG.
•  A critical need exists for physician education in modern
ECG interpretation that distinguishes normal
physiologic adaptations in athletes from abnormal
findings suggestive of pathology.
"  Drezner JA, Ackerman MJ, Anderson J, Br J Sports Med 2013;47:122-124.
Attendees/Groups
•  AMSSM
•  European Section on Sports Cardiology (EACPR)
•  European Society of Cardiology (ESC)
•  FIFA Medical Assessment and Research Center (FMARC)
•  Pediatric & Congenital Electrophysiology Society
(PACES)
•  U of Washington, Mayo Clinic, Stanford, U Conn,
Mass General, UCLA, Emory University, Children’s
Hospital of Philadelphia, Italy, Belgium, Brazil,
Switzerland, UK
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Recommendations and Considerations Related to
Preparticipation Screening for Cardiovascular
Abnormalities in Competitive Athletes: 2007 Update
“Although the ESC proposal is innovative and
based on a generally favorable long-term
experience in Italy, it cannot easily be translated
into the US medical system and environment.
On the other hand, the panel does not arbitrarily
oppose volunteer-based athlete screening
programs with noninvasive testing performed
selectively on a smaller scale in local
communities if well designed and prudently
implemented.”
!  Maron BJ et al. Circulation. 2007;115:1643-1657.
Preparticipation Cardiovascular Screening in
Young Athletes: Current Guidelines and Dilemmas
2007 AHA Consensus Guideline Update
"  AHA 12—key elements of the screening
cardiovascular examination.
"  National standard for cardiovascular screening.
"  Against the use of ECG for routine screening but
noted “The AHA panel agreed that non-invasive
testing such as the ECG can improve the
diagnostic power of the history and physical
exam. . . .”
!  Seto CK, Pendleton ME. Cur Sport Med Rep.
2009;8:59-64.
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
Medical history*
Personal history
1. Exertional chest pain/discomfort
2. Unexplained syncope/near-syncope†
3. Excessive exertional and unexplained dyspnea/fatigue, associated
with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
Family history
6. Premature death (sudden and unexpected, or otherwise) before age 50 years due
to heart disease, in #1 relative
7. Disability from heart disease in a close relative <50 years of age
8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or
dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias
Physical examination
9. Heart murmur‡
10. Femoral pulses to exclude aortic coarctation
11. Physical stigmata of Marfan syndrome
12. Brachial artery blood pressure (sitting position) §
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•  *Parental verification is recommended for high school
and middle school athletes.
•  †Judged not to be neurocardiogenic (vasovagal); of
particular concern when related to exertion.
•  ‡Auscultation should be performed in both supine and
standing positions (or with Valsalva maneuver),
specifically to identify murmurs of dynamic left
ventricular outflow tract obstruction.
•  §Preferably taken in both arms.
!  Maron BJ et al. Circulation. 2007;115:1643-1657.
Scope of Problem
•  Risk: 2 per 100,000 persons per year
•  2.5X higher than age-matched non-athletes
•  Risk increases with increasing peak intensity of
exercise and increasing level of competition
•  Athletes with underlying but undiscovered heart
disease may have 100-fold higher risk
!  Wheeler MT et al. Ann Intern Med. 2010;152:272-286.
Incidence of Sudden Cardiac Death in
Young Athletes
•  Initial estimates put number at 1:200,000 to
1:300,000 in the US.
•  More recent US studies put the number closer to
1:50,000.
•  The United States Sudden Death in Young
Athletes Registry has identified approx 115 cases
of SCD per year, or about 1 case of sudden
cardiac death every 3 days in US organized youth
sports.
!  Drezner JA. Current Opinion in Cardiology.
2008;23:494-501.
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Recommendations and Considerations Related to
Preparticipation Screening for Cardiovascular
Abnormalities in Competitive Athletes: 2007 Update
•  Prevalence of cardiovascular diseases that
predispose to sudden cardiac death in the
general athletic population is estimated to be
0.3% (3/1000).
!  Maron BJ et al. Circulation. 2007;115:1643-1657.
•  This is confirmed by several other ECG studies
with reported true-positive rates of 0.2-0.4%.
!  Drezner JA. Current Opinion in Cardiology.
2008;23:494-501.
The Athlete’s Heart: Remodeling,
Electrocardiogram and Preparticipation Screening
•  2002
•  “However, such false-positive, abnormal ECG
patterns in athletes are an important limitation
to the diagnostic power of the ECG testing in
preparticipation cardiovascular screening of
large athletic populations.”
!  Pelliccia A, Di Paolo FM, Maron BJ. Card in Rev.
2002;10:85-90.
Electrocardiography and the Preparticipation Physical
Examination: Is It Time for Routine Screening?
•  2006
•  Against including ECG due to cost and high
incidence of false-positive results.
•  “These limitations may lead to unnecessary
disqualifications and added testing, causing
much stress and anxiety for athletes, parents and
coaches.”
•  Advocated standardization of PPE on national
level.
!  Donnelly DK, Howard TM. Cur Sport Med Rep.
2006;5:67-73.
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ECG added to PPE
•  1998 study suggested 77% greater power to detect
HCM than than history and physical examination.
!  Corrado D et al. Screening for Hypertrophic
Cardiomyopathy in Young Athletes. NEJM
1998;339:364-369.
•  2006 report of 25 year study of 42,386 athletes in
Italy using history/physical/ECG showed 10-fold
reduction in the incidence of sudden cardiac death.
!  Corrado D et al. Trends in Sudden Cardiac Death in Young
Competitive Athletes After Implementation of a
Preparticipation Screening Program. JAMA
2006;296:1593-1601.
Evidence for Efficacy of the Italian National Preparticipation Screening Programme for Identification of
Hypertrophic Cardiomyopathy in Competitive Athletes
•  2006 study of 4450 elite athletes.
•  Initial screening with history/physical/ECG.
•  Follow-up with echo.
•  No definite cases of HCM identified (after ECG
before echo) although 5-10 would be expected
given prevalence of 0.1-0.2%.
Evidence for Efficacy of the Italian National Preparticipation Screening Programme for Identification of
Hypertrophic Cardiomyopathy in Competitive Athletes
Authors suggest:
"  ECG screening is effective in leading to the
diagnosis of HCM.
"  Reason for negligible SCD due to HCM in Italy is
due to ECG screening and H&P.
"  Not absolutely necessary to utilize
echocardiography as a routine diagnostic test for
the detection of HCM. May aid in identifying
other cardiac issues.
!  Pelliccia A, Di Paolo FM, Maron BJ et al. Eur Heart J.
2006;27:2196-2200.
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Cardiovascular Screening in College
Athletes With and Without
Electrocardiography
•  Prospective study.
•  508 Harvard collegiate athletes.
•  Each received hx/physical/ECG/TTE.
•  Those doing H&P blinded to ECG/TTE results.
•  H&P found 5/11 abnormalities, adding ECG
moved it to 10/11 (sensitivity up from 45% to
90%).
•  False-positive rate went from 5.5% to 16.9%.
!  Baggish AL et al. Ann Int Med. 2010; 152:269-275.
Performance of the 2010 European Society of Cardiology
Criteria for ECG Interpretation in Athletes
•  508 university athletes.
•  11 had findings suggestive of or diagnostic for
cardiac disease relevant to sport participation
risk.
•  3 met criteria for restricted sports participation.
•  505/508 cleared were followed for 2 years
without any cardiac events.
Performance of the 2010 European Society of Cardiology
Criteria for ECG Interpretation in Athletes
•  62/508 were found to have abnormal findings
"  13: H&P
"  29: ECG
"  20: H&P and ECG
•  49 (9.6%) had abnormal ECG with 2010 criteria
(down from 83 (16.3%) with 2005 criteria).
•  Sensitivity (low rate of false negatives) remained
high (.909) and specificity (false positives) improved
(from .169 to .100) or from 83% to 90%.
!  Weiner RB et al. Heart. 2011;97:1573-1577.
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ESC Criteria for ECG Interpretation in
Athletes: Better But Not Perfect
•  “False positive results raise concerns about the
unnecessary investigations, erroneous
disqualification and psychological harm to the
athlete. Conversely, SCDs in sport are highly
visible, claiming young lives.”
•  “In a cost-prohibitive financial climate the ECG
is probably the most effective tool for identifying
conditions predisposing to SCD in young
athletes.”
!  Sharma S et al. Heart. 2011;97:1540-1541.
Addition of the Electrocardiogram to the
Preparticipation Examination of College Athletes
•  2010 study--Stanford University
•  “Considering the prevalence of diseases
potentially associated with SCD. . .it has been
the consensus of the cardiologists at our
institution to recommend that ECG screening
becomes mandatory for our athletes. . .”
!  Le VV et al. Clin J Sport Med. 2010;20:98-105.
Cost Effectiveness Analysis of Screening of High
School Athletes for Risk of Sudden Cardiac Death
•  2000 cost-analysis
•  “Preparticipation cardiovascular mass screening
of HAS appears to be best accomplished through
performance of ECGs that are twice as cost
effective as the American Heart Associationrecommended specific cardiovascular history
and physical examination. Two-dimensional
echocardiography is the least cost effective
method. . .”
!  Fuller CM. Med Sci Sports Exer. 2000;32:887-890.
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Cost-Effectiveness of Preparticipation Screening for
Prevention of Sudden Cardiac Death in Young Athletes
•  Design: Decision-analysis, cost effectiveness model.
•  “…ECG plus cardiovascular-focused history and
physical examination is reasonable in cost and is
effective at saving lives.”
•  Similar cost effectiveness as dialysis, public access to
defibrillation, and implantable cardioverterdefibrillator implantation.
•  Dedicated CV screening with H&P is much more
costly and marginally more effective than no
screening.
!  Wheeler MT et al. Ann Intern Med. 2010;152:272-286.
Recommendations for Interpretation of 12lead Electrocardiogram in the Athlete
Group 1: common and training related
ECG changes
• 
• 
• 
• 
• 
Sinus bradycardia
First-degree AV block
Incomplete RBBB
Early repolarization
Isolated voltage criteria for left
ventricular hypertrophy
Corrado D et al. Eur Heart J.
2010;31:243-259.
Group 2: uncommon and trainingunrelated ECG changes
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
T-wave inversion
ST-segment depression
Pathological Q-waves
Left atrial enlargement
Left-axis deviation/left anterior
hemiblock
Right-axis deviation/left
posterior hemiblock
Right ventricular hypertrophy
Ventricular pre-excitation
Complete RBBB or LBBB
Long or short QT interval
Brugada-like early
repolarization
Accuracy of ECG Interpretation in Competitive Athletes: The Impact
of Using Standardized ECG Criteria (Drezner et al BJSM 2012)
•  40 ECG’s (12 abnormal/28 normal).
•  60 docs (22 PC residents, 16 PC attendings, 12
SM attendings, 10 cardiologists).
•  Sensitivity improvement from 89-94%
•  Specificity improvement from 70-91%
•  PPV 69-91%
•  NPV 86-94%
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“Normal Abnormals”
Joseph Marek MD SCD Conference 1/2013
•  60% of athletes have changes on ECG that may
be misconstrued as abnormal.
•  Regular and sustained exercise can lead to
changes that are a reflection of:
"  Autonomic nervous system adaptations: sinus
brady and junctional escape rhythms, sinus
arrhythmia, AV blocks.
"  Structural/electrical remodeling: IRBBB, early
repolarization, increased voltage.
Normal ECG Findings in Athletes
•  Low voltage
•  Sinus arrhythmia
•  Sinus bradycardia (>30)
•  Ectopic atrial rhythm
•  Short PR without delta waves
•  1° AVB
•  2° AVB Mobitz 1 (Wenckebach)
•  IRBBB
•  Isolated increased voltage
•  Early repolarization pattern
SCD Pearls
•  Increased QRS amplitude is not a good
distinguisher of disease when interpreting an
athlete’s ECG.
•  Early repol in Black/African athletes: elevated
ST-segment with an upward (“domed”)
convexity, followed by T-wave inversion in V2V4 (6-12% prevalence).
•  Suspect Long QT Syndrome in family with
unexplained drowning, sudden death <50, car
accidents.
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SCD Pearls (HCM)
•  >16 mm thickness always pathologic
•  Physiologic hypertrophy
"  Concentric
"  Normal cavity size
"  Normal diastology
"  No scar on MRI
•  Physiologic dilation—normal function with
exercise
•  If unsure detrain and repeat results
SCD Pearls (WPW)
•  1-3/1,000
•  Accessory connection bypassing AV node
•  Risk of reentrant SVT and SCD
•  Red flags include:
"  Younger age (<30)
"  Male gender
"  History of A-fib
"  Congenital heart disease
"  Syncope
Management of SCA in Sport
•  Must have emergency action plan and access to
AED’s.
•  Practice the plan!
•  Suspect SCA in any collapsed and unresponsive
athlete.
•  Seizure=SCA until proven otherwise.
•  AED programs save lives.
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NCAA ECG Study—Multicenter
Feasibility Trial in DI Schools
•  PPE insensitive for conditions associated with
SCD.
•  Incidence of SCD in DI athletes 4-5 times higher
than previously thought (Harmon 2011).
•  ECG has potential to increase detection of
athletes at risk.
•  Concerns for false-positive results, unnecessary
secondary investigations or disqualification, and
cost.
NCAA ECG Study—Multicenter
Feasibility Trial in DI Schools
•  Purpose: to evaluate and compare the accuracy
of cardiovascular screening in NCAA athletes
using a standardized history, physical exam, and
ECG (using Seattle Criteria).
•  Ongoing—14 NCAA DI schools-now expanding
to DII and III.
•  Any athlete without prior ECG screening was
eligible.
NCAA ECG Study—Multicenter
Feasibility Trial in DI Schools
•  2,471 male and female athletes screened.
•  7 athletes (.28%) diagnosed with serious cardiac
conditions.
•  All 7 had abnormal ECG’s.
•  2 had abnormal H or P.
•  4 athletes were upperclassmen with previous
normal H&P.
•  More data coming in but it appears false positive
rate about 3% with ECG and 30% with H.
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NCAA ECG Study—Multicenter
Feasibility Trial in DI Schools
•  Limitations: larger sample size needed for
accurate prevalence, potential for falsenegatives, low false-positive rate may not be
reproducible with less experienced
interpretation.
•  Conclusions: feasible, low false-positive with
new criteria, superior accuracy compared to
H&P alone.
•  Greater physician infrastructure needed to apply
accurate use of ECG.
Incidence of SCA In HS Athletes
(Toresdahl 2013)
•  There is no reliable SCD registry in the US.
•  Many “studies” use media reports, ins. claims…
to determine incidence, and often look at SCD.
•  Recent 2 year prospective study using National
Registry for AED Use in Sports and 2,149 high
schools.
•  Data suggests 1:58,000—more than previously
suspected—likely underreported.
•  Males 5 times higher than females.
•  Athletes 3 times higher than non-athletes.
Incidence Pearls
•  Incidence estimates are highly variable and
largely dependent on study methodology, age,
and demographics.
•  SCD in athletes is higher in:
"  M>F
"  College>HS
"  Black/African>Caucasian
"  Athletes>non-athletes
(Exercise is a risk for persons with CV disease)
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Public Health Perspective
•  Meningococcal vaccine of all incoming college
freshmen may prevent 2-5 deaths a year with a
cost per death of $22 to $48 million.
!  MMWR Recomm Rep 2005;54:1-21.
•  Disease prevalence of all cardiovascular
disorders that predispose young athletes to SCD
is 1:333. In US standard newborn screening for
phenylketonuria and cystic fibrosis; prevalence
of these is 1:15,000 and 1:3500 respectively.
!  Wash State Dept of Health 2008.
Societal Factors
•  High “shock” value of sudden cardiac death.
•  “Pressure” from parents/coaches/administrators
to start a program.
•  With obesity rates increasing in young people,
are we “helping” by looking for athletes to
disqualify?
Contemporary Approaches to the Identification
of Athletes at Risk for Sudden Cardiac Death
2008 Review
1. All athletes should undergo a comprehensive
preparticipation evaluation using a detailed personal and
family history questionnaire, along with a properly
conducted physical examination, beginning at age 12 and
repeated every 2 years.
2. A questionnaire should be administered in interval
years to assess the development of any new
cardiovascular symptoms. Blood pressure also should be
evaluated at that time.
3. ECG screening should be performed (at minimum)
upon athlete matriculation to high school and college.
Drezner JA. Current Opinion in Cardiology. 2008;23:494-501.
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Other Supportive Articles
•  Ma JZ et al. Cardiovascular Pre-participation Screening
of Young Competitive Athletes for Prevention of Sudden
Death in China. J Sci Med Sport. 2007;10:227-233.
“The 12-lead electrocardiogram and
echocardiogram should be considered and have
the potential to enhance the sensitivity of the
screening process for detection of
cardiovascular diseases…”
•  Lawless CE and Best TM. Electrocardiograms in
Athletes: Interpretation and Diagnostic Accuracy. Med
Sci Sports Exerc. 2008;40:787-798. “ECG evolving
as an adjunct to the standard PPE.”
Other Supportive Articles
•  Sofi F et al. Cardiovascular evaluation, including resting and
exercise electrocardiography, before participation in competitive
sports: cross sectional study. BMJ. 2008;337:a346. “The
inclusion of resting and exercise electrocardiography to
the standard medical evaluation of sports participation
helps to identify those at high risk.”
•  Basavarajaiah S et al. Prevalence of Hypertrophic Cardiomyopathy
in Highly Trained Athletes: Relevance to Pre-Participation
Screening. J Am Coll Cardiol. 2008;51: 1033-1039. “Screening
athletes with echocardiography is not cost effective.
However, electrocardiography is useful in selecting out
those individuals who may have pathological left
ventricular hypertrophy for subsequent
echocardiography.”
Articles Against
•  Shephard RJ. Preparticipation screening of young
athletes: an effective investment? In: Shephard RJ,
Alexander MJL, Cantu RC, et al, eds. Year Book of
Sports Medicine, 2005. Philadelphia, PA: Elsevier/
Mosby; 2005:xix-xvi.
•  Chaitman R. An electrocardiogram should not be
included in routine preparticipation screening of
young athletes. Circulation. 2007;116;2610-2615.
•  Shephard RJ. Mass ECG screening of young
athletes. Br J Sports Med. 2008;42;707-708.
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Is Electrocardiogram Screening of North
American Athletes Now Warranted?
•  2011 editorial questioning several studies
(Corrado 2006, Wheeler 2010, and Baggish
2010) related to efficacy and cost.
•  “Sudden exercise-induced death in young
athletes is an extremely rare event and attempts
to detect those individuals at risk using a resting
ECG face severe problems from limited test
sensitivity and specificity.”
!  Shephard RJ. Clin J Sports Med. 2011;21:189-190.
Mandatory Electrocardiographic Screening of
Athletes to Reduce Their Risk for Sudden Death
•  2011 Israeli study.
•  Retrospective media-information study.
•  Looked at sudden cardiac death in young athletes during
two 12 year periods, one without ECG (1985-1997) and
one with ECG (and exercise testing) added to PPE
(1998-2009).
•  11 events ’85-’97 and 13 ’98-’09.
•  Authors suggest Corrado 2006 study noted decrease
because the pre-ECG study period was too short (2
years) and the number of deaths during that period were
higher than statistics suggest it should have been.
•  Against mandated ECG screens.
!  Steinvil A et al. J AM Coll Cardiol. 2011;11:1291-1296.
Is There Evidence for Mandating
Electrocardiogram as Part of the Pre-Participation
Examination?
2011 review article looking at many of the
aforementioned studies.
"  Sensitivity of H&P alone very low. Adding ECG
increases sensitivity with a very high negative
predictive value.
"  Specificity of an abnormal ECG is low, but when
taking into account gender, level of training, and
ethnicity, this goes up.
"  Studies from Japan, Italy, and the US suggest
cost-effectiveness appears to be improving.
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Is There Evidence for Mandating Electrocardiogram as
Part of the Pre-Participation Examination?
"  Things like liability, erroneously restricting ones
ability to make a living, and negatively impacting
public perception of exercise by not reducing SCD or
over-restricting participation need to be taken into
account.
"  “Thus, cardiac pre-participation screening without
ECG cannot be recommended given our current
knowledge. . .On ethical grounds the reasons
(logistical, legal, economic) for not screening
individual athletes should be very clearly stated.
!  Borjesson M and Dellbourg M. Clin J Sport Med.
2011;1:13-17.
Electrocardiograms Should Be Included in
Preparticipation Screening of Athletes
“. . .the consequence of delays in implementing
ECG screening until more research data are
available would come at the cost of failure to
prevent deaths from occurring during the period
of time that the study effort is being conducted.”
!  Myerburg RJ and Vetter VL. Circulation.
2007;116:2616-2626.
Final Thoughts
•  In 2013 it appears that consensus is mounting for
the use of ECG as part of the PPE (local nonmandated efforts).
•  Addition of ECG to PPE in a local/team/school
setting appears to be the best method at this time.
•  While cost and logistics are important factors, we
need to be creative in working around these issues.
•  Improvements in screening criteria will likely occur
over next few years, reducing the false-positive
ECG’s—this has happened—the Seattle Criteria.
•  More physicians need to take advantage of the BMJ
ECG training module…
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ECG Module
•  Published through the British Medical Journal:
!  learning.bmj.com
!  There will be a click-through to “ECG interpretation in
athletes”
!  Free
Examples
The community heart screens are organized by the
Nick of Time Foundation (Mill Creek WA),
targeted at area high schools, free, and offered
about once per month.
http://nickoftimefoundation.org/
Full PPE with ECG. Team of Physicians for
Students (TOPS--Phoenix AZ).
http://www.aztops.org/
Key Reference Articles
•  12-lead ECG in the Athlete: Physiological versus
pathological abnormalities. Corrado D et al. Br J Sports
Med 2009;43:669-676.
•  Recommendations and Considerations Related to
Preparticipation Screening for Cardiovascular
Abnormalities in Competitive Athletes: 2007 Update.
Maron BJ et al. Circulation. 2007;115:1643-1657.
•  36th Bethesda Conference:
Eligibility Recommendations for Competitive Athletes
With Cardiovascular Abnormalities
Barry J. Maron, MD, FACC, Conference Co-Chair
Douglas P. Zipes, MD, MACC, Conference Co-Chair.
JACC 2005.
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Key Reference Articles
•  Is There Evidence for Mandating Electrocardiogram as
Part of the Pre-Participation Examination? Borjesson M
and Dellbourg M. Clin J Sport Med. 2011;1:13-17.
•  Contemporary Approaches to the Identification of
Athletes at Risk for Sudden Cardiac Death. Drezner JA.
Current Opinion in Cardiology. 2008;23:494-501.
•  Normal electrocardiographic findings: recognising
physiological adaptations in athletes. Drezner JA,
Froelicher V, et al. Br J Sports Med. 2013;47: 125-136.
•  February 2013 issue of the British Journal of Sports Medicine has
several other related articles.
Thank-you
[email protected]
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